Post-traumatic Confusion Research Articles

Rehabilitation for Impaired Attention in the Acute and Post-Acute Phase After Traumatic Brain Injury: A Narrative Review.

Impaired attention is the most common and debilitating cognitive deficit following a traumatic brain injury (TBI). Attention is a fundamental function that profoundly influences the performance of other cognitive components such as memory and execution. Intriguingly, attention can be improved through cognitive rehabilitation. This narrative review summarizes the essential elements of rehabilitation for attention problems in acute and post-acute TBI. In the acute phase of mild TBI, investigations into the medical history and daily life performance, neurological examination, screening and management of concomitant sleep-wake disorders or neuropsychiatric disorders, and support and education on the natural course of concussion are covered. Rehabilitation for patients with moderate-to-severe TBI consists of serial assessment for patients with disorders of consciousness and a post-traumatic confusion state. In the post-acute phase after TBI, components of rehabilitation include investigating medical history; neurological, imaging, and electrophysiological tests; evaluation and treatment of factors that may impact attention, including sleep-wake, emotional, and behavioral disorders; evaluation of attention function; and cognitive rehabilitation as a matter of course. We summarized metacognitive strategy, direct attention training, computer-based cognitive interventions, medication, and environmental control as interventions to enhance attention.

A Review on Post-Traumatic Aggression

Traumatic brain injury is the first cause of death and disability in children and young adults in worldwide. During the acute phase of recovery from moderate to severe brain injury, a period of post-traumatic confusion state (PTCS) will arise that is a combination of cognitive and behavioral dysfunction. Seven key symptoms of PTCS are identified and measured by Confusion Assessment Protocol (CAP) Agitation can be part of PTCS in the acute phase or, part of the recovery of consciousness in chronic phase. There are different hypothesis and classifications of acute and chronic post-traumatic aggressive syndromes. While post-traumatic aggression is common, its mechanism, assessment tool, outcome and treatment plans are not well-defined. Understanding the different aspects of post-traumatic aggression; mechanism, differential diagnosis, and treatment are reviewed in this article.

Focal Electroencephalographic Changes Index Post-Traumatic Confusion and Outcome.

While the duration and severity of post-traumatic confusional state (PTCS) after traumatic brain injury have well-established implications for long-term outcomes, little is known about the underlying pathophysiology and their role in functional outcomes. Here, we analyzed the delta-to-alpha frequency band power ratios (DAR) from localized scalp areas derived from standard resting electroencephalographic (EEG) data recorded during eyes closed state in 49 patients diagnosed with PTCS. Higher global, occipital, parietal, and temporal DARs were significantly associated with the severity of PTCS, as assessed by the Confusion Assessment Protocol (CAP) observed on the same day, after controlling for injury severity. Also, occipital DARs were positively associated with both the CAP disorientation score 2, and the CAP symptom fluctuation score 4, after controlling for injury severity (n = 35). Posterior DARs were significantly associated with Functional Independence Measure-cognitive subscale average score at 1 (n = 45), 2 (n = 42), and 5 (n = 34) year(s) post-injury. The associations at 1 (temporal left) and 2 (parietal left) years survive after controlling for an injury severity index. Our finding that posterior DAR is a marker of PTCS and functional recovery post-injury, likely reflects functional de-afferentation of the posterior medial complex (PMC) in PTCS. Altered function of the PMC is proposed as a unifying physiological mechanism underlying both acute and chronic confusional states. We discuss the relationship of these findings to electrophysiological markers associated with disorders of consciousness.

Posttraumatic Confusion Predicts Patient Cooperation During Traumatic Brain Injury Rehabilitation

Scant research has examined the relationship between posttraumatic confusion (PTC) and cooperation during rehabilitation from moderate to severe traumatic brain injury. In this study, PTC and cooperation were examined in a prospective cohort of 74 inpatients with traumatic Brain Injury. Confusion was measured using the Confusion Assessment Protocol. Cooperation was rated on a 0-100 scale by rehabilitation therapists. Using multiple regression analysis, PTC significantly predicted cooperation (R(2) = 0.33, P < 0.001). Age at injury, education, days since injury, and Glasgow Come Scale scores were not significant predictors. Bivariate analyses indicated that four PTC symptoms significantly predicted poorer cooperation: daytime hypersomnolence (ρ = -0.42, P < 0.001), agitation (ρ = -0.39, P = 0.001), psychosis (ρ = -0.39, P = 0.001), and cognitive impairment (ρ = -0.24, P = 0.04). Results provide empirical support that PTC is associated with poorer cooperation and empirical justification for interventions to manage confusion during early recovery from traumatic brain injury.

Poster 14 (see Article 3): Amantadine Hydrochloride for Treatment of Symptoms of the Posttraumatic Confusional State: A Randomized, Double-Blind, Placebo-Controlled Trial

Objective: To test the hypothesis that amantadine hydrochloride (AH), a NMDA antagonist and indirect dopamine receptor agonist, hastens resolution of symptoms of the posttraumatic confusional state (PTCS) observed during early recovery from severe nonpenetrating traumatic brain injury (TBI). Design: Randomized, double-blind, placebo-controlled, parallel group trial. Setting: Inpatient brain injury unit of free-standing rehabilitation hospital affiliated with the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems of Care. Participants: Consented neurorehabilitation admissions with posttraumatic confusion after initial nonpenetrating TBI ≤ 90 days earlier (n=79), randomly assigned to the AH (n=39) or placebo (n=40) groups. Group assignment was adjusted for baseline confusion severity at time of randomization. Intervention: AH 100mg twice daily or identical placebo for 14 days, or until confusion symptom resolution (if ≤14d) as measured by the Confusion Assessment Protocol (CAP). Main Outcome Measures: The primary outcome measure was confusion severity score as measured by the CAP after 14 days. The secondary outcome measures were (1) time to reach “nonconfused” CAP score; and (2) number of patients withdrawn from study due to predetermined, safety-related “escape” criteria. Results: There was no difference in the number of symptoms of PTCS, as measured by the CAP, between the AH and placebo-treated patients at day 14 of treatment (AH=2.56, placebo=2.7; Wilcoxon Mann-Whitney rank-sum test P=0.57). However, the mean difference in time to first “nonconfused” CAP score between groups approached significance (AH=7.7d, placebo=9.3d; Cox survival P=.053). No patients were withdrawn due to fulfillment of safety-related escape criteria. Conclusions: Although the natural course of symptom recovery from PTCS is favorable, these results provide tentative support to reports suggesting that AH safely hastens recovery from nonpenetrating TBI.

Poster 19: What Should Be the Operational Threshold for Emergence From Minimally Conscious State?: Empirically Derived Insights From Clinical Evaluation of Patients With Posttraumatic Confusion

Objective: To evaluate the utility of the operational threshold for emergence from posttraumatic minimally conscious state, by determining yes-no accuracy to questions of varying difficulty, including simple orientation questions, among responsive participants. Design: Prospective study in a consecutive sample of traumatic brain injury admissions. Setting: Inpatient brain injury rehabilitation program. Participants: 144 responsive participants from 184 consecutive Traumatic Brain Injury Model System admissions.

Effect of Severity of Post-Traumatic Confusion and Its Constituent Symptoms on Outcome After Traumatic Brain Injury

Sherer M, Yablon SA, Nakase-Richardson R, Nick TG. Effect of severity of post-traumatic confusion and its constituent symptoms on outcome after traumatic brain injury. ObjectiveTo investigate the prognostic significance of severity of post-traumatic confusion (PTC) and its constituent symptoms for early and late outcome after traumatic brain injury (TBI). DesignProspective cohort study. SettingInpatient brain injury rehabilitation program. ParticipantsA total of 168 patients meeting study criteria from 195 consecutive Traumatic Brain Injury Model Systems neurorehabilitation admissions. InterventionsNot applicable. Main Outcome MeasuresEmployability at neurorehabilitation discharge and productivity status at 1 year postinjury. ResultsMore severely confused patients had poorer outcomes for both employability and productivity. Multivariable logistic regression revealed that after adjustment for all other predictors, time to follow commands, and confusion severity predicted employability at discharge and age and confusion severity predicted productivity status at 1 year. Each symptom showed an unadjusted effect on discharge employability. All symptoms except nighttime sleep disturbance or daytime decreased arousal had effects on productivity at 1 year. Presence of psychotic-type symptoms was associated with especially poor productivity outcomes. ConclusionsPTC constituent symptoms and severity predict outcome after TBI. Presence or absence of psychotic-type symptoms on a single evaluation at approximately 21 days postinjury may have particular prognostic significance for productivity outcome.

Recovery from mild concussion in high school athletes

Object. A computerized neuropsychological test battery was conducted to evaluate memory dysfunction and self-reporting of symptoms in a group of high school athletes who had suffered concussion. Methods. Neuropsychological performance prior to and following concussion was compared with the test performance of an age-matched control group. Potentially important diagnostic markers of concussion severity are discussed and linked to recovery within the 1st week of injury. Conclusions. High school athletes who had suffered mild concussion demonstrated significant declines in memory processes relative to a noninjured control group. Statistically significant differences between preseason and postinjury memory test results were still evident in the concussion group at 4 and 7 days postinjury. Self-reported neurological symptoms such as headache, dizziness, and nausea resolved by Day 4. Duration of on-field mental status changes such as retrograde amnesia and posttraumatic confusion was related to the presence of ...

Acute confusion following traumatic brain injury

Primary objective: To determine the incidence, duration and symptoms associated with acute confusion/delirium among traumatic brain injury (TBI) neuro-rehabilitation admissions.Research design: Prospective evaluation of neurobehavioural impairments following TBI among inpatient neurorehabilitation admissions.Methods and procedures: Eighty-five consecutive TBI model system patients were evaluated using measures of orientation, cognition, motor restlessness and delirium.Main outcomes and results: Fifty-nine individuals met Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition Delirium Diagnostic Criteria (DDC) on initial evaluation and 42 of these resolved delirium during inpatient rehabilitation. Multivariable logistic regression analyses revealed significant unique associations of the Galveston Orientation and Amnesia Test (GOAT), Delirium Rating Scale, Cognitive Test for Delirium and time elapsed since injury with DDC status.Conclusions: Findings indicate that delirium is common among neuro-rehabilitation admissions with TBI. Use of a single measure (e.g. GOAT) will result in poor characterization of the multi-faceted symptom complex shown by patients with post-traumatic confusion.

Recovery from mild concussion in high school athletes.

A computerized neuropsychological test battery was conducted to evaluate memory dysfunction and self-reporting of symptoms in a group of high school athletes who had suffered concussion. Neuropsychological performance prior to and following concussion was compared with the test performance of an age-matched control group. Potentially important diagnostic markers of concussion severity are discussed and linked to recovery within the 1st week of injury. High school athletes who had suffered mild concussion demonstrated significant declines in memory processes relative to a noninjured control group. Statistically significant differences between preseason and postinjury memory test results were still evident in the concussion group at 4 and 7 days postinjury. Self-reported neurological symptoms such as headache, dizziness, and nausea resolved by Day 4. Duration of on-field mental status changes such as retrograde amnesia and posttraumatic confusion was related to the presence of memory impairment at 36 hours and 4 and 7 days postinjury and was also related to slower resolution of self-reported symptoms. The results of this study suggest that caution should be exercised in returning high school athletes to the playing field following concussion. On-field mental status changes appear to have prognostic utility and should be taken into account when making return-to-play decisions following concussion. Athletes who exhibit on-field mental status changes for more than 5 minutes have longer-lasting postconcussion symptoms and memory decline.

RETROGRADE MEMORY IMMEDIATELY AFTER CONCUSSION

Progressive retrograde amnesia was noted in four football players who, after concussion, had definite post-traumatic confusion but knew the immediate preconcussive event. They then lost this retrograde memory over a period of a few minutes. Apparently the fixation of short-term memory requires more than rehearsal and is interfered with by the continuing effects of a concussive injury in the post-trauma period.